American College of Physicians: Internal Medicine — Doctors for Adults ®


In the News
for the Week of 3-23-10


  • Health care reform heads to president to sign, while fixes head to Senate for debate
  • Guidelines aim to prevent unnecessary death from thoracic aortic disease
  • Internists generated $1.6 million annually for affiliated hospitals

Test yourself

  • MKSAP Quiz: dyspnea, chest tightness in an adolescent athlete


  • Older colon cancer patients less likely to receive chemo, have fewer late adverse events

Preventive care

  • Scoring system predicts risk for hospital readmission


FDA update

  • Additional lots of clevidipine butyrate injectable emulsion recalled
  • Boxed warning for clopidogrel: reduced effects for certain patients

From the College

  • Match Day results better but not good enough for primary care
  • ACP receives distinguished recognition from ACCME
  • ACP seeks representative to accreditation review commission

Cartoon caption contest

  • Vote for your favorite entry

Physician editor: Darren Taichman, FACP


Health care reform heads to president to sign, while fixes head to Senate for debate

Health care reform passed the U.S. House of Representatives Sunday night.

The legislation looks to:

  • prohibit lifetime caps on insurance policies and prohibit denying care and coverage for pre-existing conditions.
  • mandate that individuals obtain health insurance,
  • cover 32 million more Americans,
  • establish a health insurance “exchange,”
  • close Medicare's doughnut hole and expand Medicaid and
  • limit physician ownership of hospitals,

While the bill itself goes to the White House for signature by the president, negotiations on a companion bill with fixes to the original renew in the Senate Tuesday morning.

ACP applauded the measure, which ACP president Joseph W. Stubbs, FACP, called "historic."

“ACP has long advocated for these and other reforms, and we are pleased that they have passed the House today," Dr. Stubbs said.


Guidelines aim to prevent unnecessary death from thoracic aortic disease

Clinical guidelines offer new recommendations to diagnose and manage thoracic aortic disease (TAD), based on earlier detection and treatment, consideration of varied presentation of the condition, and a new understanding of risk factors such as family history.

Recent scientific and clinical advances drove the development of guidelines to help physicians diagnose and manage forms of TAD. Also, noninvasive imaging and medical therapy have improved, as has the understanding of genetics and family history.

Guidelines developed by a multidisciplinary group that included ACP appear in the April 6 Journal of American College of Cardiology.

Physicians should ask patients not only about close relatives with aortic aneurysm, dissection or rupture, but also about any family history of unexplained sudden death. Risk factors for TAD include poorly controlled high blood pressure, advancing age, male gender, atherosclerosis, inflammatory diseases that damage the blood vessels, and genetic conditions that weaken connective tissue, such as Marfan syndrome. Pregnancy, intense weight lifting and cocaine use increase the risk of aortic dissection.

Additional guidelines include:

  • Imaging of the thoracic aorta by computed tomography, magnetic resonance imaging or echocardiography is the best way to detect TAD and determine future risk. A chest X-ray alone is not sufficient.
  • Patients with genetic conditions that increase the risk of TAD should have aortic imaging at the time of diagnosis to establish the size of the aorta, with periodic follow-up imaging thereafter.
  • All patients with a bicuspid aortic valve should be evaluated to determine whether the aorta is dilating.
  • Symptoms of acute aortic dissection can mimic those of a heart attack. Physicians should keep aortic dissection in mind when asking questions about medical history, family history and the type and pattern of pain when examining the patient.
  • All immediate relatives of a patient with thoracic aortic aneurysm or dissection, or a bicuspid aortic valve, should be evaluated by a cardiovascular physician and undergo aortic imaging to measure the size of the aorta and identify asymptomatic disease.


Internists generated $1.6 million annually for affiliated hospitals

A general internist generated $1,678,341 in one year on average for an affiliated hospital, a family physician $1,622,832 a year, and a pediatrician $856,154 a year, reports a survey by a physician search firm.

Physicians of all specialties generated an average of $1,543,788 a year in net revenue on behalf of an affiliated hospital, according to a press release by recruiters Merritt Hawkins. Hospital CFOs reported finances by their choice of calendar or fiscal year. Results are online. The revenue is slightly more than in the 2007 survey, in which all specialties averaged $1,496,432 in net revenue.

Merritt Hawkins asked hospital chief financial officers nationwide (114 respondents) to quantify how much net inpatient and outpatient revenue was generated by 17 specialties in terms of patient referrals, tests and procedures performed in the hospital.

Other top revenue-generating specialties included:

Neurosurgeons $2,815,650
Cardiologists $2,240,366
Orthopedic surgeons $2,117,764
General surgeons $2,112,492
Hematologists/oncologists $1,485,627


Test yourself

MKSAP Quiz: dyspnea, chest tightness in an adolescent athlete

An 18-year-old male high school football player is evaluated for recurrent episodes of dyspnea, chest tightness and cough that have occurred during a game and limited his ability to participate. The symptoms resolve spontaneously in 20 to 30 minutes. The patient's father has known allergies but no known lung disease.

On physical examination, the patient is a healthy young man; the lungs are clear on auscultation. Office spirometry shows an FEV1 of 90% predicted and FEV1/FVC 80%.

Which of the following is the most appropriate next step in the evaluation of this patient?

A) Measure lung volumes and diffusion capacity
B) Perform an exercise challenge test
C) Perform allergy skin testing
D) Prescribe a physical conditioning program

Click here or scroll to the bottom of the page for the answer and critique.



Older colon cancer patients less likely to receive chemo, have fewer late adverse events

Adjuvant chemotherapy after stage III colon cancer resection is effective in older patients, but isn't always administered due to concerns about adverse events. Older patients who do receive the therapy, however, get lower doses and durations than recommended. In addition, late clinical adverse events are less common than in younger patients, a new study reports.

Researchers analyzed adjuvant chemotherapy and adverse events by age in 675 patients diagnosed with stage III colon cancer from 2003 through 2005 who underwent colon resection. Results were published in the March 17 Journal of the American Medical Association.

Of 202 patients aged 75 years and older, 101 (50%) received adjuvant chemotherapy compared with 87% of 473 younger patients (difference, 37%; 95% CI, 30% to 45%). Among patients who received adjuvant chemotherapy, 14 patients (14%) aged 75 years and older and 178 younger patients (44%) received a regimen containing oxaliplatin (difference, 30%; 95% CI, 21% to 38%), which has been shown to be more effective but also more toxic.

Older patients were less likely to continue treatment at all follow-up times. By 150 days, 99 patients (40%) aged 65 years and older and 68 younger patients (25%) had discontinued chemotherapy (difference, 15%; 95% CI, 7% to 23%).

Overall, 162 patients (24%) had at least one adverse clinical event, with more events among patients treated with than without adjuvant chemotherapy (mean, 0.39 vs. 0.16; difference, 0.23; 95% CI, 0.11 to 0.36; P<0.001). Among patients receiving adjuvant chemotherapy, adjusted rates of late clinical adverse events were lower for patients 75 years and older (mean, 0.28) than for younger patients (0.35 for ages 18 to 54 years, 0.52 for ages 55 to 64 years, and 0.45 for ages 65 to 74 years; P=0.008 for any age effect).

Chemotherapy is meant to prolong survival for patients with at least five years of life expectancy. Women and men age 70 have a median life expectancy of 16.2 and 13.7 years, respectively, and those age 80 and older have a median life expectancy of 9.8 and 8.2 years, respectively, "suggesting that adjuvant chemotherapy should be considered for many older patients," the authors wrote.


Preventive care

Scoring system predicts risk for hospital readmission

A prediction model using patient characteristics can help identify those at risk for early readmission to the hospital, according to a new study.

Researchers performed a prospective observational cohort study to determine whether it was possible to predict which patients were more likely to be readmitted to the hospital within 30 days of discharge. The study population involved 10,946 patients, 7,287 in the derivation cohort and 3,659 in the validation cohort, who were discharged from the general medicine service at six academic medical centers. Readmissions were determined from administrative data and from telephone follow-up 30 days after discharge. The authors looked at sociodemographic factors, social support, health condition and health care utilization and used logistic regression to determine which variables were associated with early readmission. The study results appear in the March Journal of General Internal Medicine.

In each cohort, 17.5% of patients were readmitted to the hospital within 30 days. In the derivation cohort, the following factors were associated with early readmission:

  • insurance status,
  • marital status,
  • having a regular physician,
  • Charlson comorbidity score,
  • SF12 physical component score,
  • at least one hospital admission within the past year, and
  • a current length of stay longer than two days.

Scores were calculated by multiplying the beta-coefficient by 10 and rounding to the nearest integer. An overall risk score of 25 points or higher identified 5% of patients with a 30% risk for readmission in both the derivation and validation cohorts. Although marital status and having a regular physician seemed to be unusual predictors of early readmission, the former could result in being discharged home rather than an acute care facility and the latter could indicate the presence of more severe illness, the authors wrote.

The authors noted that their model had only fair discrimination and acknowledged that their results should not be generalized to settings other than academic medical centers, among other limitations. However, they concluded that the factors in this model help identify patients who are at risk for being readmitted to the hospital soon after discharge.

“More work is needed to identify additional factors that impact post-discharge health outcomes, optimize the discharge process for all patients, and create interventions tailored to patients’ needs in order to prevent potentially avoidable readmissions,” the authors wrote.



Incidence of nonmelanoma skin cancer increasing

Incidence of nonmelanoma skin cancer has increased substantially in the U.S., according to a new study.

Researchers analyzed Medicare and national survey data to determine incidence of skin cancer procedures in 1992 and from 1996 to 2006, as well as office visits for nonmelanoma skin cancer. Incidence was defined as both newly diagnosed nonmelanoma skin cancer and persons who were newly diagnosed, with the former as the primary definition. The authors used data on treatment procedures for skin cancer to estimate the number of cases. The study results appear in the March Archives of Dermatology.

Overall, skin cancer procedures in Medicare fee-for-service patients increased 76.9% from 1992 to 2006, while the annual age-adjusted procedure rate per 100,000 beneficiaries rose from 3,514 to 6,075. Skin cancer procedures in Medicare patients increased 16% from 2002 to 2006, while procedures per affected patient and persons who had at least one procedure increased by 1.5% and 14.3%, respectively. The authors estimated that in 2006, approximately 3.5 million nonmelanoma skin cancers and approximately 2.2 million people were treated in the U.S.

The authors acknowledged that they equated one skin cancer procedure with one incident skin cancer when determining incidence, among other limitations. However, they concluded that rates of nonmelanoma skin cancer have increased “dramatically” in the U.S. from 1992 to 2006. In light of these results, and because educational programs urging sun safety have not been widely effective, “continued national research and programs on treatment, education, and prevention are critical,” the authors wrote.


FDA update

Additional lots of clevidipine butyrate injectable emulsion recalled

Four additional lots of hypertension drug clevidipine butyrate injectable emulsion (Cleviprex) are being recalled because particulate matter has been seen in some vials, the FDA said in a safety notice.

The additional lots being recalled are 68-407-DJ (expires August 2010); 68-408-DJ (expires August 2010); and 71-101-DJ and 71-106-DJ (expire November 2011). Eleven other lots were recalled in December 2009 due to particulate matter that was found to be inert stainless steel particles. If the particles aggregate, or if larger particles are present, they could reduce blood flow in capillaries, cause mechanical damage to some tissues, or initiate inflammatory reactions. Ischemia or organ insufficiency could then occur, the notice said.

Affected lots should be returned through the pharmaceutical wholesaler/distributor, the FDA said.


Boxed warning for clopidogrel: reduced effects for certain patients

A boxed warning was added to the label for clopidogrel (Plavix) to warn of reduced effectiveness in patients who metabolize the drug poorly, the FDA said last week.

Tests are available to identify genetic differences that may affect metabolic ability, and health care professionals should consider using other medications or alternative clopidogrel dosing strategies in patients identified as poor metabolizers, the FDA said. Although a higher dose regimen (600 mg loading dose followed by 150 mg once daily) in poor metabolizers increases antiplatelet response, an appropriate dose regimen for poor metabolizers hasn't been established in a clinical outcome trial, the agency said.

It is estimated that 2% to 14% of the population are poor metabolizers, the FDA said. The agency added information about this subset of patients to the drug's label in May 2009.


From the College

Match Day results better but not good enough for primary care

The number of U.S. medical students choosing internal medicine residencies inched higher from 2009 but not enough to significantly impact the shortage of primary care physicians, according to an ACP statement on 2010 Match Day results. ACP Council of Student Members Jonathan Stegall and Ryan VanWoerkom talked to ACP about their own Match Day experience.


ACP receives distinguished recognition from ACCME

The Accreditation Council for Continuing Medical Education (ACCME) has awarded ACP Accreditation with Commendation, a distinction awarded to a small minority among 713 providers accredited by ACCME. ACP’s new term of accreditation continues until March 31, 2016. ACCME's decision was based on a review of an ACP self-study report, evidence of performance-in-practice, and ACP’s accreditation interview with two ACCME surveyors last October. In addition to meeting the requirements, ACCME commended ACP for demonstrating engagement in an environment supportive of quality improvement by facilitating physician learning. This is the second consecutive time ACP has received Accreditation with Commendation.


ACP seeks representative to accreditation review commission

ACP is seeking a representative to the Accreditation Review Commission on Education for the Physician Assistant (ARC-PA), which reviews and accredits physician assistant training programs. The position is for a three-year term with eligibility for a second three-year term. The ARC-PA meets twice per year, once in March and once in September. The next scheduled meetings are March 3-5, 2011 in Savannah, Ga. and September 8-10, 2011 in St. Louis, Mo. ACP is one of the sponsoring organizations of ARC-PA.

Each member is responsible for reviewing and preparing reports on two to seven PA programs, representing three to six hours of work per program. Program files to be reviewed at the meetings are made available at least two weeks beforehand. A laptop computer is required. Each member is also expected to participate in one on-site program visitation each review cycle (that is, two visits per year), involving approximately 1.75 days of work per visit. New members are expected to attend an orientation.

Representatives receive no compensation for their services, but all expenses related to the ARC-PA are reimbursed. Interested ACP members should send their CV and the name and contact information of a single reference to Patrick Alguire, FACP, director of education and career development.


Cartoon caption contest

Vote for your favorite entry

ACP InternistWeekly's cartoon caption contest continues. Readers can vote for their favorite caption to determine the winner.

"We had to clone our interns to meet the latest work hour rules."
"So, what's alien you?"
"We had a rough year in the Match."
"They thought I was discussing a problem with Uranus."

Go online to pick the winner, who receives a $50 gift certificate good toward any ACP program, product or service. Voting continues through March 29, with the winner announced in the March 30 issue.


MKSAP answer and critique

The correct answer is B) Perform an exercise challenge test. This item is available online to MKSAP 14 subscribers in the Pulmonology and Critical Care Medicine section, Item 57.

ACP's Medical Knowledge Self-Assessment Program (MKSAP) allows you to:

  • Update your knowledge in all areas of internal medicine
  • Prepare for ABIM certification or recertification
  • Support your clinical decisions in practice
  • Assess your medical knowledge with 1,200 multiple-choice questions

To order the latest edition of MKSAP, go online.

Exercise-induced asthma is a common manifestation of asthma. Nearly 90% of patients with asthma have exercise-induced asthma, provided adequate exercise intensity. Cold, dry air can enhance its occurrence. Exercise challenge (to >85% of maximal predicted heart rate) with post-exercise spirometry showing a 100% or greater reduction in FEV1 confirms the diagnosis of exercise-induced asthma. Exercise challenge test has a high specificity for the diagnosis when the reduction in FEV1 postexercise is 15% or greater. Airway obstruction after exercise peaks in 5 to 15 minutes and resolves in 20 to 30 minutes. Treatment with short-acting inhaled β-agonists 5 to 10 minutes before exercise prevents exercise-induced asthma in more than 80% of patients. With appropriate management, affected patients can engage in physical activity and do not need to limit or stop their involvement in sports. Lung volumes and diffusion capacity measurements are helpful in evaluating patients with suspected parenchymal lung diseases and are not likely to help in this patient. Although patients with parenchymal lung disease have dyspnea on exertion, their symptoms are typically progressive. Allergy skin test could be done in this patient at some point; positive results would not explain the patient's symptoms and would not be expected to change his management. Deconditioning manifests as dyspnea on exertion but is not typically associated with cough or chest tightness; therefore a physical conditioning program would be very helpful in this patient.

Key Points

  • Exercise-induced asthma is confirmed by exercise challenge (to >85% of maximal predicted heart rate) with post-exercise spirometry showing a 20% fall in FEV1.
  • Treatment with short-acting inhaled β-agonists 5 to 10 minutes before exercise prevents exercise-induced asthma in more than 80% of patients.

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ACP InternistWeekly is a weekly newsletter produced by the staff of ACP Internist. It is automatically sent to all College members who have an e-mail address on file with ACP.

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Copyright 2010 by the American College of Physicians.


Test yourself

A 67-year-old man is evaluated for a recent diagnosis of primary hyperparathyroidism after an elevated serum calcium level was incidentally detected on laboratory testing. Medical history is significant only for hypertension, and his only medication is ramipril. Following a physical exam and lab studies, what is the most appropriate management of this patient?

Find the answer

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